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Blood Clotting Complications in Dialysis

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Complications in Dialysis

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Abstract

Dialysis was not practical until the development of heparin, and to this day, it is the mainstay anticoagulant used in therapy. Therapy increases antithrombin activity, thus preventing clotting. Clot formation is the end result of two cascading processes, one related to external injury and the other an intrinsic system to prevent abnormal internal thrombus formation, particularly when the vessel wall is damaged. These mechanisms rely on a series of serine protease enzymes to activate downstream “factors.” Platelets are critically packaged to carry granules that are essential for clotting, and the timing of their release enables the platelet plug that precedes the clot. Vitamin K is a cofactor that factors II, VII, IX, and X depend on. Calcium is also essential for clot formation. Platelets, vitamin K, and calcium may be disordered in kidney disease. Toxins that comprise the uremic milieu can also either exacerbate or impede normal homeostasis. Clotting and inflammation are linked, and the increased oxidants associated with kidney disease play a role in clotting disorders. Hemodialysis patients are unique in that they are dependent on anticoagulants, may have disorders in calcium metabolism, and may have dialyzer-induced platelet aggregation. Several disorders commonly seen in dialysis patients require management that targets either calcium, vitamin K, platelets, or specific serine protease factors. The arteriovenous access is particularly vulnerable to thrombosing, and regular surveillance is necessary for early detection. Everyday disorders like atrial fibrillation react differently to standard therapy in dialysis patients. A recent clinical trial did not support the use of direct oral anticoagulants (DOACs) in dialysis-based atrial fibrillation, and other studies have had variable results. Head trauma is particularly common in dialysis patients. The increased risks of falling make the use of anticoagulants a major concern when designing management strategies for elderly dialysis patients. Any unwitnessed fall should lead to the suspicion of a potential intracranial bleeding episode. Other major adverse consequences related to dialysis, particularly when anticoagulants are necessary, include gastrointestinal bleeding.

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  1. Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Stephen Z. Fadem

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  1. Section of Nephrology, Baylor College of Medicine, Houston, TX, USA

    Stephen Z. Fadem

  2. Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil

    José A. Moura-Neto

  3. Salisbury, VT, USA

    Thomas A. Golper

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Fadem, S.Z. (2023). Blood Clotting Complications in Dialysis. In: Fadem, S.Z., Moura-Neto, J.A., Golper, T.A. (eds) Complications in Dialysis. Springer, Cham. https://doi.org/10.1007/978-3-031-44557-6_8

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